1. Does he/she check up on you and want to know where you are at all times?
Often Sometimes Rarely Never

2. Is he/she jealous and does he/she accuse you of having affairs with other people?
Often Sometimes Rarely Never

3. Does he/she tell you that you're worthless, stupid, lazy, ugly, fat, a failure, etc.?
Often Sometimes Rarely Never

4. Does he/she call you obscene names?
Often Sometimes Rarely Never

5. Does he/she make fun of you in front of other people?
Often Sometimes Rarely Never

6. Does he/she tell you that no one else could ever love you or want you?
Often Sometimes Rarely Never

7. Does he/she try to keep you from seeing family or friends, ridicule them or try to turn you against them?
Often Sometimes Rarely Never

8. Does he/she control what you wear, where you go, or who you see?
Often Sometimes Rarely Never

9. Does he/she forbid or demand that you work or, if you want to work, does he/she make it difficult for you to spend your money?
Often Sometimes Rarely Never

10. Does he/she call you a lot or check up on you at school or work?
Often Sometimes Rarely Never

11. Does he/she tell you that no one would ever hire you?
Often Sometimes Rarely Never

12. Does he/she try to keep you from driving a car by taking your keys or a part off the engine?
Often Sometimes Rarely Never

13. Does he/she have dramatic mood swings?
Often Sometimes Rarely Never

14. Does he/she become angrier when drinking?
Often Sometimes Rarely Never

15. Does he/she try to make you have sex when you don't want to?
Often Sometimes Rarely Never

16. Does he/she ever force or pressure you to commit sexual acts that you are not comfortable with or consider unnatural?
Often Sometimes Rarely Never

17. Has he/she ever broken or damaged your possessions and/or property or dumped garbage in your home?
Often Sometimes Rarely Never

18. Has he/she ever hurt and/or killed a pet in order to frighten or punish you?
Often Sometimes Rarely Never

19. Does he/she ever force you to stay awake?
Often Sometimes Rarely Never

20. Does he/she ever slap, punch, kick, bite, choke, pull your hair and/or burn you?
Often Sometimes Rarely Never

21. Does he/she ever lock you in a room, car and/or out of the house?
Often Sometimes Rarely Never

22. Does he/she ever push you, shove you against the wall and/or restrain you by holding you to prevent you from leaving a room?
Often Sometimes Rarely Never

23. Does he/she ever hurt you with an object or weapon (gun, knife, cigarette, rope, belt, etc.)?
Often Sometimes Rarely Never

24. Has he/she ever threatened you with an object or weapon?
Often Sometimes Rarely Never

25.Does he/she ever endanger you by reckless driving?
Often Sometimes Rarely Never

26. Does he/she neglect you when you are sick or in need of medical help?
Often Sometimes Rarely Never

27.Has he/she ever threatened to commit suicide, kill you, your family members or friends?
Often Sometimes Rarely Never

28. Has he/she ever molested anyone or behaved in an inappropriate, flirtatious way?
Often Sometimes Rarely Never

29. Has he/she ever been violent toward your siblings or his/her own siblings?
Often Sometimes Rarely Never

30. Has he/she ever been violent to other people at school or in public places?
Often Sometimes Rarely Never

31. Have you ever had to call the police or wanted to because you feared him/her?
Often Sometimes Rarely Never

32. Has he/she ever been arrested for violence?
Often Sometimes Rarely Never

33. When he/she senses that you cannot stand the abusive behavior any longer and are thinking about leaving, does he/she try to manipulate you into staying by making you feel guilty, threatening suicide, threatening to hurt or kill you, etc.?
Often Sometimes Rarely Never